Дисертації з теми "Health"

This is an inter-disciplinary argument for a moral entitlement to a capability to be healthy. Motivated by the goal to make a human right to health intelligible and justifiable, the thesis extends the capability approach, advocated by Amartya Sen and Martha Nussbaum, to the theory and practice of the human health sciences. Moral claims related to human health are considered at the level of ethical theory, or a level of abstraction where principles of social justice that determine the purpose, form, and scope of basic social institutions are proposed, evaluated, and justified. The argument includes 1) a conception of health as capability, 2) a theory of causation and distribution of health capability as well as 3) an argument for the moral entitlement to a sufficient and equitable capability to be healthy grounded in the respect for human dignity. Moreover, the entitlement to the capability to be healthy is defended against alternative ethical approaches that focus on welfare or resources in evaluating and satisfying health claims. In specific, it is argued that human health is best understood as a capability to be healthy - a meta-capability to achieve a cluster of basic and inter-related capabilities and functionings. Such a cluster of capabilities and functionings is in line with Martha Nussbaum's central human capabilities. A theory of causation and distribution of health capability is put forward that integrates the 'classic' biomedical factors of disease (genetic endowment, exposure to hazardous materials, behaviour), social determinants of disease, and Drèze and Sen's econometric analysis of the causation and distribution of acute and endemic malnutrition. Furthermore, the argument critiques Norman Daniels's revised Rawlsian theory of health justice, and advocates for the capability approach to recognize group capabilities in light of 'population health' phenomena. Lastly, the thesis also argues that a coherent, capability conception of health as a species-wide conception will tend to make any theory of justice recognizing health claims a cosmopolitan theory of justice.

The focus of this dissertation is on the role of multiplayer digital games in adult education, with a particular emphasis on health education. Although interest in the use of digital games for serious applications has been increasing since the early 2000s, there is a significant gap in understanding on the use of multiplayer digital games in adult education. In the context of health education, there has been a large amount of research conducted in to the use of repurposed commercial games for predicting performance of trainees and health students on surgical simulators. However, beyond this niche research into game based learning is notably less cohesive. There has been some research into the use of digital games in areas such as for delivering insulin management training, but understanding of the processes for widespread application of games based learning in the health sector is limited. Additionally, almost no research has been undertaken into the use of multiplayer digital games in health education, whether it be for tertiary or adult learners. In this dissertation two digital games were developed, implemented and evaluated to explore the value of multiplayer games for supporting cooperation and collaboration in health education. The first game, They Know: Anatomy, was a real time team based strategy game designed to support anatomy revision by second year medical students. The second game, the Qstream: Cancer Cup Challenge, was a team based asynchronous online program designed to reinforce understanding of how to identify and manage adverse events by oncology registrars. A design research framework informed the methodology used in this dissertation. This framework emphasises the need to use multiple iteration cycles to develop a comprehensive understanding of player experiences with the digital games they encountered. Data on participant experiences with the digital games was collected using qualitative methods, including post-game surveys and semi-structured interviews. Between iterative cycles data on participant experiences with the digital games were analysed so that future implementations of the game could be modified to maximise cooperation and collaboration between players. At the conclusion of the study period data collected across all implementations of the digital games were analysed to increase understanding of how multiplayer digital games supported cooperation and collaboration between learners. Findings from this dissertation demonstrate that multiplayer digital games can be used to engage medical students in anatomy revision and medical oncologists in adverse events retraining. This is the first study to look at the use of digital games for either of these demographics. Additionally, this dissertation identified four ways through which multiplayer digital games foster collaboration between players: through the development of a team strategy to win the game, by facilitating !iii shared decision making, by working towards a shared goal, and by creating a sense of investment in a team. Finally, findings from this dissertation contribute to the literature on the implementation of game based learning in adult education. This is an under researched area, but one that warrants further focus in future if game based learning is going to be successfully incorporated into curricula and training activities for adult learners. This dissertation adds to the literature by presenting new knowledge on how and why multiplayer games support collaboration between learners. Additionally, it appears that multiplayer digital games offer diverse, flexible and immersive experiences to adult learners in a way that single player digital games may not. Finally, multiplayer digital games provide new avenues for support self-directed learning by encouraging cooperation between large groups of students in a manner that is not normally achieved in online learning environments

La combinació de més d'un strategia metodològica (com el màrqueting social, la participació de la joventut, l'educació dirigida per iguals i l'ús dels mitjans de comunicació social) i strategias de cambio de antorn (intervenció basada en l'escola, basada en la intervenció restaurant, basat en la família de la intervenció) pot augmentar l'eficàcia de involucrar els joves en les intervencions de salut destinades a fomentar hàbits i estils de vida saludables. Aquesta tesi té com a objectiu comprendre els factors que intervenen en l'epidèmia de l'obesitat juvenil a tot el món i com influeixen en l'obesitat. En resposta a aquest desafiament global, aquest treball proporciona estratègies basades en proves científiques innovadores, eficaces i de qualitat per millorar els estils de vida saludables entre els joves. Aquestes estratègies podrien donar lloc a un enfocament d'investigació més fort que podrien beneficiar tant a la comunitat científica i el coneixement general de les parts interessades i els responsables polítics, fomentant així un enfocament multidisciplinari participatiu i inclusiu per obtenir resultats duradors i eficaços
La combinación de más de una estrategía metodológica (como el marketing social, la participación de la juventud, la educación dirigida por pares y el uso de los medios de comunicación social) y/o de una estrategia de cambio de entorno (intervención basada en la escuela, basada en la intervención restaurante, basado en la familia de la intervención) puede aumentar la eficacia de involucrar a los jóvenes en las intervenciones de salud destinadas a fomentar hábitos y estilos de vida saludables. Esta tesis tiene como objetivo comprender los factores que intervienen en la epidemia de la obesidad juvenil en todo el mundo. En respuesta a este desafío global, este trabajo proporciona estrategias basadas en pruebas científicas innovadoras, eficaces y de calidad para mejorar los estilos de vida saludables entre los jóvenes. Estas estrategias podrían dar lugar a un enfoque de investigaciónque podrían beneficiar tanto a la comunidad científica y el conocimiento general de las partes interesadas en prevenir este problema así como a responsables políticos, fomentando así un enfoque multidisciplinario participativo e inclusivo para obtener resultados duraderos y eficaces.
The combination of more than one methodological (such as social marketing, youth involvement, peer-led education and social media usage) and environmental (school-based intervention, restaurant-based intervention, family-based-intervention) strategy may increase the effectiveness of engaging young people in health interventions aimed at encouraging healthy habits and lifestyles. This thesis aims to understand the factors involved in the worldwide youth obesity epidemic and how they influence obesity. In response to this global challenge, this work provides innovative, effective and quality scientific evidence-based strategies for improving healthy lifestyles among young people. These strategies could lead to a stronger research approach that could benefit both the scientific community and the general knowledge of relevant stakeholders and policy makers, thus fostering a participatory and inclusive multidisciplinary approach for long-lasting and effective results.

Personal health can influence all aspects of customer behavior and this influence is more manifest within the senior market segment. Health issues also greatly impact the restaurant industry. Therefore, the purpose of this study was to investigate how health status and health attitude influence family restaurant selection criteria. In order to measure selfrated health status and health attitude for seniors, the Health Perceptions Questionnaire(HPQ) and the Perceived Health competence Scale (PHCS) were used. Most senior participants reported that health-related family restaurant selection criteria and food price were important when they select a family restaurant. Also, while the HPQ and the PHCS were not correlated with food price in the family restaurant industry, the overall results of this study revealed that health status and health attitude for seniors were positively correlated with health-related family restaurant selection criteria. This reflects that offering healthy meals on menus is more important for senior customers with a high level of health condition or health attitude than other senior customers. The results also showed that healthy senior customers who have a positive health attitude are willing to pay more money for their healthy menu items. Therefore, in order to maximize their profits, managers and operators of family restaurants need to keep creating healthy items for their menus and promote those items to the segment of the senior market which has a high level of health condition or health attitude.
Master of Science

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine.
BACKGROUND: The prevalence of childhood obesity has tripled in the past 30 years. There are many published recommendations to address pediatric obesity, yet countless physicians are challenged by the time and resources required to provide obesity screening and counseling in a busy practice. OBJECTIVE: To determine the effects of a motivational interviewing (MI) program and an electronic health record (EHR) reminder system to improve physician performance in identifying and counseling patients about obesity prevention and management. METHODS: Baseline and two post‐intervention cohorts were created with patients, ages 5‐18 years, from 100 consecutive well child visits at an academic teaching practice in Feb 2014, Feb 2015, and Aug 2015. The HEALTH model was created to improve care by providing in‐room family education tools, provider training in MI, an evidence‐based pathway to standardize care, and family coaching between visits. The model was implemented using quality improvement methodology. A second intervention added an alert in the EHR to notify providers if a patient’s body mass index (BMI) was > 85%ile. Outcome measurements included documentation of BMI percentiles, identification of overweight/obesity in the problem list, quantity and quality of healthy lifestyle counseling, and recommending follow up for BMI monitoring per prevention guidelines. P‐values were calculated using Chi‐Squared or Fisher’s Exact tests. RESULTS: Post HEALTH implementation, physicians improved their identification of patients with elevated BMI, improved the quantity and quality of healthy lifestyle counseling, and increased compliance with prevention plus recommendations for follow up. Providers increased their rates of identifying and counseling patients with obesity from a baseline of 50% to 76% (HEALTH) to 85% (EHR alerts). Post HEALTH intervention, physicians increased counseling about screen time and sleep (p<0.001) while maintaining high rates of counseling about nutrition, exercise and minimizing sugary beverages. Providers increased documentation of a specific, individualized action plan from 33% of the time at baseline to 59% post HEALTH intervention (p<0.001). Physicians increased recommendations for patients with elevations in BMI post intervention (p<0.005). CONCLUSIONS: After implementation of the HEALTH model and electronic reminders, physicians significantly improved their performance in identifying and counseling patients with elevated BMI. They also increased performance in counseling abouthealthy lifestyle behaviors for patients of all BMI categories. The HEALTH quality improvement model combined with electronic alerts provides a means to implement evidence‐based obesity prevention guidelines into clinical practice.

In 2003, the Swedish Parliament adopted a national public health policy that included the domain - “A more health-promoting health service”. Strategies and tools are needed in the work to reorient health services. Personal health documents are documents concerning a person’s health, and are owned by the individual. Several studies that have evaluated such documents indicate that they could be of interest in health-promotion work. However, there is insufficient knowledge concerning personal health documents that target adolescents, and little is known about the feasibility of such documents in a Swedish cultural context. The concept of empowerment is gaining increased interest for health services, but the associations between empowerment, self-rated health and health behaviour are sparsely studied. The overall aim of the thesis is to explore a strategy - empowerment - and a tool - personal health documents - that might facilitate the work of the public health goal of a health-promoting health service. Specific aims are to examine the feasibility of using personal health documents in health promotion; to examine professionals’ experiences of working with health promotion and personal health documents; to examine the association between personal health documents and self-reported health behaviour change; and to examine the perception of empowerment in relation to self-rated health and health behaviour among adolescents. Two personal health documents that targeted adults and adolescents were developed and evaluated. Distribution to adults in different settings was compared in a cross-sectional study (n = 1 306). Adolescents received the document in school, and surveys were performed at baseline and after one year (n = 339). Practical use and attitudes by document owners were studied by questionnaires. Teachers (n = 69) answered a questionnaire, and community health nurses were interviewed (n = 12). The interviews also explored nurses’ experiences of working with health promotion in general, and were analysed by qualitative methodology. Adolescents’ empowerment was examined by a questionnaire (n = 1 046). Most participants reported reading in the documents; writing in the documents varied between 16% (distribution in occupational health) and 87% (adolescents). The health document was perceived as useful by 35% of the adolescents. Factors significantly related to personal usefulness were being born outside Sweden, experiencing fair treatment by teachers, being a non-smoker and having a positive school experience. Community health nurses were striving for a balance of being a doer of practical, disease-oriented tasks and a health-promotion communicator. The structural organisation in health care centres was important for their work with health promotion and the health document. Teachers were generally in favour of continued work with the document. In different settings, between 10% and 26% of adults reported changes in their health situations as a result of reading the booklet. Self-reported changes in health situations were less likely using postal distribution, and there were no significant differences between the other types of distribution. Adolescents with low empowerment scores reported poorer self-rated health and more risk-taking behaviours such as smoking and binge drinking. To conclude, personal health documents are feasible to use in different settings. Health promotion in health services needs active support from leaders as well as adequate support systems. Findings suggest that personal health documents can be tools for promoting self-reported lifestyle changes among adults in different settings. There is a close relation among adolescents between low empowerment in the domain of health, low self-rated health and health behaviours such as binge drinking and smoking.

The UK has one of the highest teenage pregnancy rates in Western Europe and young people are disproportionately affected by high rates of sexually transmitted infections. An experimental evaluation of a sexual health promotion DVD entitled, “Bedroom Business,” was undertaken to assess its capacity to change the cognitive antecedents of condom use. Bedroom Business is a 27 minute documentary featuring young people and health professionals discussing sexual health. The DVD also tells the story of five local young people who write and produce a song which focuses on the risks of unsafe sex and underlines the importance of using condoms. Schools were randomised to either no intervention (control) or presentation of the DVD followed by group discussion (intervention). Participants were 147 students aged 16-18. The DVD was evaluated in terms of its capacity to change 13 cognitive antecedents of condom use through a self-report questionnaire. Participants completed the questionnaire at baseline and at four week follow-up. Analysis of covariance, with baseline scores as covariates, showed there were no differences between the conditions on any of the variables. The DVD itself was very popular, with nearly all the students responding that they would recommend it to other young people. Qualitative feedback revealed many young people found it appealing because it featured other young people. The implications of the study are discussed in the wider context of research into sexual health interventions. It is suggested interventions that are greater in scope and duration, holistic in nature and which aim to change future life opportunities for young people may serve to be the most effective.

Over the past decade there have been increasing amounts of academic, political and media interest in Physical Education. teachers and their role in promoting healthy, active. lifestyles. Indeed, there is a long-standing assumption that schools play a fundamental role in producing 'a healthy nation' arid that Physical Education is responsible for promoting sport, physical activity and health amongst young people. This research was located within the context of Health-Related Exercise (HRE), a statutory component of the National Curriculum for Physical Education in England which aims to promote in pupils the knowledge, skills and understanding necessary to lead healthy, active lifestyles. An extensive and critical review of literature revealed that there were continuing concerns over the status, organisation and teaching of HRE within the curriculum, and that questions had been raised over Physical Education teachers' knowledge of HRE and the extent to which they have engaged with continuing professional development (CPD) in the area (HRE-CPD). The reasons underpinning these concerns have been relatively unexplored and this thesis represents a contribution towards understanding the social processes which have served to influence the nature and extent of Physical Education teachers' engagement with HRE and HRE-CPD.

Health care reform has been described as a global epidemic. This thesis deals with nature and experience of health care reform in developing countries. Increasing privatisation, economic transition, and structural adjustment have provided the context for health system changes. Different approaches to reform have been developed by international organisations such as the World Bank, WHO and UNICEF. What has driven national health care reforms? Are such policies really appropriate to developing countries? Has a consensus now emerged in relation to international health policy? Has a new health care ‘model’ appeared? The study of health care reform in Cambodia is a timely opportunity to investigate the implementation of health care reform under extreme conditions. These conditions include a legacy of genocide, long-term conflict, political isolation, and economic transition. This case study uses both qualitative and quantitative methods and multiple sources of data to analyse the reform program. The study reinforces the conclusion that, under conditions of extreme poverty, market based reforms are likely to have limited positive impact. Rather, understanding the cultural conditions that determine demand, delivering health care of a satisfactory quality, providing appropriate incentives for health practitioners, and supporting services with adequate public funding are the prerequisites for improved service delivery and utilisation. Cambodia's strategy of integrated district health service development and universal population coverage may provide an instructive example of reform. Emerging policy issues identified by this case study include the fundamental role of equity in service provision, the influence of the social determinants of health and illness and interest in the appropriate use of evidence in international health policy-making.

Childhood obesity is a major public health concern for Americans. Many school-based health interventions and campaigns have been in place in the elementary school setting to help lower the rates of childhood obesity and to make students aware of their health. This study focuses on the implementation of the Healthy Monday campaign to fourth and fifth grade students in two Kentucky elementary schools. Particularly the focal points of the campaign consist of nutrition and physical activity. The campaign highlights two spin-off campaigns from the Healthy Monday campaign titled the Monday Mile and Meatless Monday. This study looks at the effectiveness of the overall health campaign to the fourth and fifth grade students, their parents, and teachers in the two schools. Pre and post surveys were developed in order to test four components of the health campaign: campaign awareness, attitudes, nutrition knowledge, and behavior change. This study shows that the health campaign increased student’s awareness, nutrition knowledge, and behavior change. Also the parent and teacher population showed significant increase in campaign awareness and behavior change. Overall, the health campaign created awareness among all three populations.

This thesis explores the interconnections between masculinity, health and prison. It contests reductionist, individualist and biomedical approaches to health care management in prisons and challenges gender-blindness within criminology and social science where masculinities have been overlooked as key factors of prison culture and organisation. The research set out to explore how masculinities manifest at institutional, social and cultural levels in prison as key determinants of health. The study was conducted in an enhanced wing of an adult male training prison in Southern England. A reflexive ethnographic approach was used, comprising sustained (non-participant)observation, focus group interviewing, and in-depth, semi-structured interviews with thirty-five inmates and four prison officers. The research revealed how prison masculinities were produced and performed by inmates and prison staff, and through the discourses and practices of the prison regime. They were manifested at social and organisational levels as key determinants of health as 'deprivations' associated with imprisonment and as 'importation factors' reflecting inmates pre-prison health status. Values of the institution and those of inmates and staff combined to create a pervasively 'masculine' atmosphere and culture, which adversely affected the physical and mental health of many prisoners. This thesis recommends that health policy for prisons is developed and organised with consideration to issues of gender and power. The masculine ideology that underpinned the organisational and social fabric of the prison in this study was evident in the attitudes and behaviours of inmates and staff and in the 'progressive regime' advocated by the Prison Service. This research shows that a broad, holistic and 'gendered' view of prison health can provide alternative insight into men's health in prisons, and therefore offer a positive and productive way forward for future prison health policy, in line with the World Health Organisation's Healthy Prisons philosophy.

Research focused on health behaviors of online graduate students is sparse. Health psychology graduate training prepares individuals to share health information with others; the information may be more credible if they present a healthy appearance. The present study tested concepts from social cognitive theory (general perceived self-efficacy) and self-determination theory (autonomy, competence, and relatedness basic needs) to determine predictive value for graduate students’ engaging in health behaviors. Participants were 121 (29 health psychology group, 92 other programs group) online graduate students who lived in the United States and attended the same online university, recruited from multiple social media sources. The study used a static comparison quasi-experimental design to examine data from an online survey. Data were analyzed using Pearson correlation, chi-square tests for independence, independent samples t-tests, ANOVA, MANOVA, and binary logistic regression. The health behaviors did not differ between the two graduate student groups. General perceived self-efficacy, autonomy, relatedness, and competency mean scores did not predict engaging in health behaviors. A significant negative correlation for the total sample was found between autonomy and body mass index. Positive social change may result from research focused on the best means to encourage health psychologists to regularly engage in health behaviors to the extent of Centers for Disease Control and Prevention recommended levels. By internalizing and modeling good health, health psychologists will add credibility to their message and help to mitigate the connection between premature death from chronic disease due to lack of engaging in a voluntary healthy lifestyle.

Overview The program of research presented in this thesis was designed to increase understanding of the central issues related to Indigenous peoples’ hospitalisation experiences. Emphasis was given to Indigenous peoples’ cardiovascular health care. This area was chosen because cardiovascular disease has been described as one of the major contributors to the health disparity between Indigenous and non-indigenous peoples in Australia. This was of interest to me because the main study setting is a cardiothoracic hospital. This hospital is the largest referral centre for cardiac conditions in Queensland, surrounding states, and neighbouring countries, including Papua New Guinea. This program of research comprised four studies. The first study, a metasynthesis, was undertaken to gather a worldwide perspective of Indigenous peoples’ experiences of acute care. In the second study, a narrative inquiry was undertaken. It focused on Indigenous Australians’ experiences of acute cardiac care. The third study was a systematic review. It adopted a broader perspective to investigate the effectiveness of Australian Indigenous cardiovascular health programs. The final study, an autoethnography, utilised reflective inquiry to examine issues related to researching with Indigenous people. Background There are many explanations given to explicate sources of health disparities for Indigenous people. Most of the factors have their roots in past colonialism and its policies. Past practices by former Australian governments devalued the Indigenous culture, tortured individuals both physically and psychologically, and effectively marginalised the Indigenous population. Indigenous people still experience elements of tacit and overt discriminatory practices within the healthcare system. A range of cultural and Indigenous-specific factors also impact Indigenous health in a negative way. As a result, Australian Indigenous people encounter noteworthy health inequalities when compared to non-Indigenous Australians. In recognition and response to this disparity in health status, the Australian government launched a “Close the Gap” campaign in 2008. The campaign attempts to narrow the health differences and life expectancy, while also considering other factors that impact Indigenous health such as education and employment opportunities. Coming to hospital is a challenge for most Indigenous Australians. In Australia, Indigenous people are often geographically isolated in scattered settlements, and living in relatively small communities, leading to fragmented services and support for health and social programs. They are isolated both geographically and culturally when they come to hospital. In most cases, they have to relocate in order to access the services they need. This experience can be overwhelming due to the different culture of hospital practices and world views of healthcare professionals, who are mainly from westernised backgrounds. In most healthcare settings, Indigenous peoples’ culture and views of health have not been integrated into mainstream health. In a way, Indigenous people are forced to leave their way of life at home and adapt to western culture when hospitalised. This can cause discomfort for Indigenous people in many ways. As a result, some avoid accessing health services even when such services are needed and are available to them. A few aspects of Indigenous culture may be presented in hospital settings but usually at tokenistic or symbolic levels. This includes items such as flags at the front of the hospital and Indigenous paintings on display. Health professionals’ attitudes, as well as the hospital policies that guide their practice, do not usually accommodate Indigenous values into practice. Bedside manners and ward practices have remained the same for many years – fashioned and practiced in the ways of the dominant culture. In Australia, cardiovascular disease is known to constitute one of the major single causes of ill health and death for Indigenous peoples. As a result, it contributes significantly to life expectancy differentials between this population and other Australians. Indigenous Australians suffer major gaps in health status even when compared with other Indigenous peoples in other first-class nations. This includes Indigenous peoples from Canada, New Zealand and the United States of America. Health practitioners, therefore, need to be aware and proactively act on the underlying causes of poor health outcomes among Indigenous people. Methods Four studies were conducted over the period of this program of research using qualitative and quantitative research methods. The first study was a metasynthesis of qualitative research studies. Its aim was to investigate current evidence of Indigenous peoples’ hospital experiences in order to summarise current knowledge. Systematic procedures were employed to retrieve studies from the period between 2000 to 2016. The review process was conducted following Joanna Briggs Institute (2014) guidelines for conducting systematic review and synthesis of qualitative data. The second study utilised narrative inquiry, a qualitative methodology in which face to face interviews were used to enable participants to recount their experiences of hospitalisation. Narrative inquiry was selected specifically because it involves storytelling, which is culturally familiar to Indigenous people. The aim was to explore Indigenous peoples’ experiences of hospitalisation of acute cardiac care. To accomplish this, data were collected using a purposeful sample of Indigenous cardiac participants: all Indigenous patient participants had been hospitalised for acute cardiac care. The third study was a systematic review. Its aim was to investigate the effectiveness of cardiovascular health care programs designed for Indigenous Australians. Analysis of the strategies that were used to achieve successful outcomes was conducted. Studies that used experimental designs and reported interventions or programs explicitly aimed at improving Indigenous cardiovascular health were considered for inclusion. The search period was between 2008 to 2017. The fourth study was an autoethnography. This study involved use of personal diary-based data and reflective inquiry to present a researcher perspective of the experience of conducting research with Indigenous people. The aim was to share the experience to inform others of aspects for consideration when conducting research with Indigenous participants. The purpose was to offer a true picture of conducting research from my perspective. The study enabled examination of the interplay of my personal, social, professional life and how these impact on my clinical and research practice. Findings The metasynthesis revealed that overall, Indigenous peoples, worldwide, have remained in a disadvantaged position when it comes to their health and wellbeing. Several factors were identified that contribute to widespread inequality in Indigenous healthcare. It was increasingly clear that current healthcare systems are not effectively working well in addressing Indigenous peoples’ health needs. The findings of the narrative inquiry indicated that three themes characterised Indigenous peoples’ experiences of hospitalisation which were as follows: the impact of the past, reality of the present, and anticipating the future in Australia. Hospitalisation remains a challenge for Indigenous peoples. This is due to a sense of dislocation and lack of cultural and spiritual aspects to care, as well as the persisting poor relational interactions encountered. Quantitative research studies that implemented interventions targeted for management of cardiac conditions among Indigenous population within Australia were included in the systematic review. The results revealed that there were limited published studies targeted specifically towards Indigenous Australians’ cardiac health improvement. However, positive outcomes were reported in terms of achieving clinical targets. Physical aspects such as blood pressure reduction, exercise attendance, and enhancing cardiac health knowledge in biomedical interventions for the Indigenous communities were the main focus. The autoethnography revealed that with adequate preparation and involvement of Indigenous people the research process can be made easier. Again, because of past experiences which have led Indigenous people to be over researched with little feedback to them; researching this population group is challenging. Most researchers in the past have conducted research that has not effectively benefited the community. In some cases, research outcomes have misrepresented participants through use of methodologies that are not appropriate for Indigenous peoples. It is not unusual for Indigenous peoples to view the word “research” as a “dirty” word that brings uncomfortable feelings. In some instances, Indigenous participants have not seen its benefits of the research or understood the outcomes. Conclusions In summary, the program of research appraised current evidence. Further, it presented new knowledge that can inform and support practitioners in their quest to progress Indigenous peoples’ healthiness and welfare. Highlighting issues from Indigenous peoples ’perspectives can facilitate development of a better understanding of issues that impact their experiences with healthcare institutions. Such revelations can help in the identification of limitations faced by health professionals or constraints they encounter in the delivery of healthcare among Indigenous people. This could assist in revealing issues that are barriers to being effective in designing and implementing effective strategies to improve Indigenous health and wellbeing. Further research is warranted to follow up on the issues identified in this research.

Social inequalities in health remain a major social issue globally. One possible explanation of health inequality is health selection: in other words people with poor health move down the social hierarchy. This study started with the conceptual distinction between two types of health selection studies. Type I health selection study (the presence of health selection) examines the impact of poor health on the subsequent social mobility. On the contrary, type II study (the contribution of health selection to social inequalities in health) examines whether health selection changes social inequalities in health. The first 13 waves (1991-2003) of the British Household Panel Survey with 63599 observations from 8819 individuals were used. In accordance with the typology, two different approaches were applied to empirical and theoretical investigation. For type I study, a multilevel multinomial model to fit all possible transition from multiple origins was used to assess social mobility with regard to health status. For type II study, both empirical and hypothetical analyses are applied in order to address the relationship between social mobility, health selection, and social inequalities in health on the population-level framework. Findings from the type I study presented that health selection was negligible in mobility within employment indicated by class and income measures, although it was highly significant in the transition between employment and non-employment. In type II study, changes in social inequalities in health were associated with a set of elements extracted from a social mobility process. Varying levels of health selection and scales of social mobility result in different extents of change in social inequalities in health.

¿Que vemos en la tv? Yo veo, desde hace mucho tiempo los canales de Discovery, porque la voz calmada, las historias irrelevantes y la sensación de estar aprendiendo algo nuevo, me ayudan a relajarme. Sin embargo hay uno de los canales que ha cambiado con el tiempo y ya no me gusta tanto. Discovery Health ahora es Home and Health y en lugar de las enfermedades misteriosas, las operaciones y los programas que mostraban cómo funciona el cuerpo humano, ahora se centra en lo que, creo, deben ser los cuatro problemas más grandes de la sociedad estadounidense: Sobrepeso, niños malcriados, matrimonios a punto de fracasar y personas mal vestidas.

The Ontario Heart Health Program has completed Phase I of a province-wide cardiovascular disease prevention program that employs community-based coalitions. Full-time heart health coordinates support the coalitions, but many coordinators left during Phase I, reducing coalition membership and compromising functioning. This thesis employed focused ethnography to explore the role, and turnover among heart health coordinators. A selective document review and thirteen telephone interviews with coordinators, chronic disease managers and coalition members from five different health units, found coordinators were challenged by: (1) an atypical job, (2) a lack of knowledge/experience (3) overwork, (4) a lack of support and recognition, and (5) coalition responsibilities. Coordinators required an understanding of the organizational structures, mandates, and funding requirements of the health unit, and the Ministry of Health and Long Term Care so they could mediate conflict, build relationships and advocate for heart health coalitions. Implications for education, practice, research and policy are discussed.

Australia has decades of public policy experience attempting to overcome the disparities in health outcomes facing Aboriginal and Torres Strait Islander (Indigenous) Australians. Significant resources have accompanied these policy initiatives, however, Indigenous Australians continue to bear a heavier burden of death, disease, disability and economic hardship than other Australians. Despite the policy experience of Australia and widespread support for initiatives to overcome Indigenous disadvantage, there is little consensus on the best means to actually do so. Working to ensure that available resources are used in their most effective way possible is vital to improving the health of Australia’s Indigenous populations. At its broadest level, health economics is the study of the choices made in the allocation of scarce resources to improve the health status of populations and service delivery. Notwithstanding the political, moral and economic importance of the issue, there remains limited health economic research in the field of Indigenous health nor is there a developed evidence base to provide guidance to policy-makers looking to invest in cost-effective interventions. Further, health economic methods have been criticised as potentially inappropriate for the area of Indigenous health. Current methods for economic evaluation tend to adopt a reductionist approach based on a cost per health outcome paradigm and are potentially insensitive to the outcomes and processes that Indigenous people see to be of value to their health and health care on three broad and related levels. First, Indigenous conceptions of health have been shown to differ from the biomedical notions which tend to underlie the reductionist approach of health economic evaluations. Second, a central tenet of Indigenous health care is community ownership and control of healthcare services. As such there is value associated with how well services achieve engagement with communities which may also be missed through a reductionist health economic approach. Third, social determinants of health have also been demonstrated to be particularly important to the health outcomes of Indigenous Australians but again have tended to lie outside the domain of traditional economic evaluation methods. Potentially because of these and other difficulties, resource allocation decisions in the field of Indigenous health have been made without a strong economic evidence-base and have instead seemingly relied on rights-based arguments promoting investment based on the sizeable need that these communities face. While there is no denying the stark disadvantage facing Australia’s Indigenous populations, such rights-based arguments provide little guidance on how much to invest or on trade-offs between different policy options or individual service components. Further, the weight attributed to such arguments has tended to vary according to the prevailing political climate. Health economic approaches on the other hand, can provide evidence based on value that can transcend politics and lay the foundation for rational priority-setting that maximises the health of target populations. Ignoring the realities of resource scarcity in the sector will not allow policy interventions to maximise the health outcomes for Australia’s Indigenous communities. Health economic methods such as discrete choice experiments (DCEs) and contingent valuation studies have been used to value factors outside of traditional economic evaluations in other fields yet have been largely untested in Australian Indigenous populations. Such techniques potentially represent a direct means through which to incorporate Indigenous values and preferences into the evaluation and design of health programs and ultimately a mechanism for the sector to demonstrate the value and impact that properly designed services can have. There is limited empirical understanding of the role of culturally-specific healthcare providers in terms of the service use patterns of these communities and overcoming the barriers that face Indigenous Australians attempting to access health services. Examining these issues through an economic lens is likely to provide a level of guidance to policy-makers that is currently absent from Indigenous health policy in Australia. This thesis explores these issues through a mixed-methods approach investigating the application and merits of a variety of health economic methods in these populations. Chapter 1 introduces the major issues in the field and provides an overview of the published literature carried out to date. Chapter 2 presents a more detailed investigation of the economic evaluation literature with a systematic review of published economic evaluations investigating health interventions in Indigenous populations around the world. The review finds relatively limited economic evaluation of health care interventions for Indigenous populations in Australia or globally, however, what has been done has demonstrated the potential for cost-effective interventions in these populations. Almost no consideration of alternative conceptions of health or Indigenous-specific values were found through the review. Chapter 3 examines this issue further, investigating the use of health-related quality of life (HRQoL) instruments in these populations, one of the most direct method to incorporate Indigenous conceptions of health into evaluations of health programs, through a systematic review of the use of these instruments in Indigenous populations around the world. The review found that while HRQoL instruments have been used to elicit the quality of life of Indigenous populations their use was relatively limited, as was evidence of the validation of these instruments in these population groups. The evidence that does exist suggests that some Indigenous populations potentially conceptualise these issues fundamentally differently to populations in which these tools have been designed and validated. Chapter 4 discusses the findings of the reviews presented in Chapters 2 and 3 in light of the Australian policy context. The chapter argues that the policy environment has emphasised rights-based rather than economic arguments in resource allocation decisions that has left room for efficiency and equity improvements in the way that resource allocation decisions are made in the field of Indigenous health. Given this, the chapter calls for further work to investigate the service utilisation of Indigenous populations and the role of culturally-specific healthcare providers and incorporate Indigenous values to value programs to improve Indigenous health including through contingent valuation and discrete choice experiment methodologies. Chapter 5 takes up the first of these issues with an analysis of the healthcare expenditure of a cohort of Indigenous and non-Indigenous Australians at high-risk of cardiovascular disease to investigate the relative service utilisation of the two groups. The analysis finds that when individuals are engaged with care providers, culturally-specific providers were providing equivalent care to mainstream providers in non-remote areas and factors other than patient Aboriginality seem to be more important in determining the healthcare expenditure of these high-risk patients. The chapter also highlights problems with current data collections in the field that acts to obscure analysis of service utilisation patterns of Indigenous Australians, particularly in remote areas, and comparisons between the relative service use of Indigenous and non-Indigenous Australians. Chapter 6 further investigates the role of culturally-specific service providers through a DCE attempting to value the cultural component of a fall-prevention service. The chapter presents the findings of a DCE carried out in a cohort of older Aboriginal people receiving a culturally-specific fall-prevention intervention. The chapter demonstrates that DCEs provide a potential means to incorporate the preferences of Indigenous communities into the design and evaluation of health services. A value for the cultural component of the service was derived through the DCE and the relative importance of different barriers to care to the decision-making of the participants were investigated. Chapter 7 presents the findings of a contingent valuation study investigating the value that the Australian community places on holding a driver licence as an example of a social determinant that has been shown to be associated with positive health outcomes in Indigenous populations. The analysis finds contingent valuation techniques can provide a means to value social determinants of health that lie outside traditional health economic evaluations and to value broader policy interventions to improve living standards. Chapter 8 puts forward the main findings of this thesis arguing that the health economics field has an important role to play in improving the health of Australia’s Indigenous populations. Appropriate targeting of available resources is essential to close the gap in health outcomes between Indigenous and non-Indigenous Australians. Economic research is vital to build an evidence-base for policy makers looking to invest in cost-effective policy options and this needs to be based on factors that Indigenous communities consider important to their health and healthcare. Potential for economic evaluation of programs needs to be a key consideration in resource allocation decisions in the field. These need to be robust enough to incorporate the factors that are important to Indigenous Australians. The role of culturally-specific providers needs to be better understood as do the different components that make up such a service. Finally, incorporating social determinants of health into the health policy environment remains crucial in the field of Indigenous health. Given the political, moral and economic importance of overcoming the disparities faced by Australia’s Aboriginal and Torres Strait Islander communities, the relative lack of health economic research in the sector is a failing of the field in Australia. Building an economic evidence base will assist those working in the sector to demonstrate the value of appropriately designed, culturally acceptable healthcare services and decision-makers in the field to move beyond rights-based arguments for funding decisions. Collectively this will enable a system of rational priority-setting in the sector whereby the health impacts derived from scarce resources are maximised.

In contemporary Western nursing, the notion of health is considered a basic concept in all nursing theory, yet the many nursing theorists have failed to express unanimity in their various descriptions of health. This situation exists even while the achievement of health is generally identified as the goal or purpose of nursing. In Australia, the requirement that nurses become health-promoting practitioners assumes that nurses understand health in positive ways, which can be translated into nursing practice. Given the myriad definitions of health, confusion among nurses about the nature of health as it is to be promoted appeared possible, even probable.This phenomenological research aimed to illuminate the nature of nurses' understandings of health and the ways such understandings are translated into nursing practice. The purpose of the study was to describe and interpret nurses' experiences of health, and their experiences of giving health care to someone in their care, in order to illuminate the nature of health for nurses and in nursing.The manner in which this research was carried out was informed by the human science approach to phenomenology described by van Manen, which is derived from the traditions of Husserl, Heidegger and Merleau-Ponty. Thus, the inquiry was grounded in the hermeneutic phenomenological philosophical perspective, which began with the work of Husserl who recognised the need to return to the grounding of truths in human experience. The thesis is informed by two views of phenomenology. The first involves the traditional approach to phenomenology advocated by the European phenomenological philosophers while the second approach is referred to by Silverman as arising from 'American continental' philosophy.Data were generated from multiple audiotaped interviews with each of nine participants, and from personal reflection and journalling undertaken by the researcher during the research process. The dual data analyses were guided by the phenomenological approach of van Manen and by that of various nursing scholars who have used phenomenological methodology as it has evolved from American continental philosophy. These analyses included several levels of reflection undertaken by the researcher and each of the participants in the study to illustrate the nature of health in nurses' lives and in nursing.The nature of health, as revealed through the original experience of the participants, was disclosed as manifest in the lives of the participants with most descriptions conveying a sense of contentment that showed as feelings of happiness, feeling alive, complete, energised and optimistic. Health also revealed itself as transient in nature, passing quickly and without notice into and out of the lives of most of the participants. Although obvious in some ways, health simultaneously eluded clear description and, even at the completion of the exploration with each participant, was characterised by an atmosphere of elusiveness. For all the participants, health was an embodied phenomenon with a common element of energy and a sense of wellbeing. These, together with a sense that life was manageable and achievable gave to it a distinctive spirit, even while the spirit simultaneously helped to make life manageable and achievable and thus contributed to health. For all of those who participated, health presented as having the ability to transform their emotional responses to daily life events in such a way that it made those events more acceptable and the tasks of life more achievable.Although health showed as a physical, embodied state which was expressed as vitality and energy, it could not be separated from the mental / emotional state. As it was described, the following leitmotifs of health were lexically revealed: Health: A different encounter for each person, Health described as peace, Health described as feeling good about oneself, Health described as balance, Health as energy, Health as vitality and zest, Health described as happiness and/or contentment, Health described as quality of life, The 'picture of health', Health described as dignity, and Health as the unknown or the inexpressible.The nature of health-focused care in nursing showed as caring, rapport building and support, ever dependent on the social relationship that develops between each nurse-carer and the individual to whom they offer care. However, clear relationships between the meanings of health for the nurses in the study and the way they gave health care could not be elucidated. These relationships have not been identified because of the individualistic nature of health-focused care as these nurses have described it. For this reason, this research makes a strong plea for continued dialogue about the relationships between health and health-focused care in nursing.

In contemporary Western nursing, the notion of health is considered a basic concept in all nursing theory, yet the many nursing theorists have failed to express unanimity in their various descriptions of health. This situation exists even while the achievement of health is generally identified as the goal or purpose of nursing. In Australia, the requirement that nurses become health-promoting practitioners assumes that nurses understand health in positive ways, which can be translated into nursing practice. Given the myriad definitions of health, confusion among nurses about the nature of health as it is to be promoted appeared possible, even probable.This phenomenological research aimed to illuminate the nature of nurses' understandings of health and the ways such understandings are translated into nursing practice. The purpose of the study was to describe and interpret nurses' experiences of health, and their experiences of giving health care to someone in their care, in order to illuminate the nature of health for nurses and in nursing.The manner in which this research was carried out was informed by the human science approach to phenomenology described by van Manen, which is derived from the traditions of Husserl, Heidegger and Merleau-Ponty. Thus, the inquiry was grounded in the hermeneutic phenomenological philosophical perspective, which began with the work of Husserl who recognised the need to return to the grounding of truths in human experience. The thesis is informed by two views of phenomenology. The first involves the traditional approach to phenomenology advocated by the European phenomenological philosophers while the second approach is referred to by Silverman as arising from 'American continental' philosophy.Data were generated from multiple audiotaped interviews with each of nine participants, and from personal reflection and journalling undertaken ++
by the researcher during the research process. The dual data analyses were guided by the phenomenological approach of van Manen and by that of various nursing scholars who have used phenomenological methodology as it has evolved from American continental philosophy. These analyses included several levels of reflection undertaken by the researcher and each of the participants in the study to illustrate the nature of health in nurses' lives and in nursing.The nature of health, as revealed through the original experience of the participants, was disclosed as manifest in the lives of the participants with most descriptions conveying a sense of contentment that showed as feelings of happiness, feeling alive, complete, energised and optimistic. Health also revealed itself as transient in nature, passing quickly and without notice into and out of the lives of most of the participants. Although obvious in some ways, health simultaneously eluded clear description and, even at the completion of the exploration with each participant, was characterised by an atmosphere of elusiveness. For all the participants, health was an embodied phenomenon with a common element of energy and a sense of wellbeing. These, together with a sense that life was manageable and achievable gave to it a distinctive spirit, even while the spirit simultaneously helped to make life manageable and achievable and thus contributed to health. For all of those who participated, health presented as having the ability to transform their emotional responses to daily life events in such a way that it made those events more acceptable and the tasks of life more achievable.Although health showed as a physical, embodied state which was expressed as vitality and energy, it could not be separated from the mental / emotional state. As it was described, the following leitmotifs of health were lexically revealed: Health: ++
A different encounter for each person, Health described as peace, Health described as feeling good about oneself, Health described as balance, Health as energy, Health as vitality and zest, Health described as happiness and/or contentment, Health described as quality of life, The 'picture of health', Health described as dignity, and Health as the unknown or the inexpressible.The nature of health-focused care in nursing showed as caring, rapport building and support, ever dependent on the social relationship that develops between each nurse-carer and the individual to whom they offer care. However, clear relationships between the meanings of health for the nurses in the study and the way they gave health care could not be elucidated. These relationships have not been identified because of the individualistic nature of health-focused care as these nurses have described it. For this reason, this research makes a strong plea for continued dialogue about the relationships between health and health-focused care in nursing.

Recent interest in identifying and measuring health outcomes represents an advance in our understanding of how health care for individuals should be evaluated. However, the concept of health outcomes has mainly focussed on improvements in health status. Non-health outcomes of health care may also be important to patients. In this thesis, four tasks were undertaken with the aim of identifying non-health outcomes and establishing the extent of their relevance and importance to patients. First, the illness experience literature was reviewed to identify potential non-health outcomes. Seven categories of non-health outcomes were identified: information, being treated with dignity, being able to trust the health care provider, having distress recognised and supported, participating in decision making, legitimation and reassurance. Second, to gain an in-depth understanding of these concepts, topic-specific literature was reviewed and synthesised. Third, in order to confirm how relevant and important the concepts were to patients, a qualitative study was conducted with each of two different groups of health service users. Broadly, patients considered that all the non-health concepts were relevant, although the extent to which they were important varied. Fourth, to test the relative importance of the seven concepts, a Stated Preference Discrete Choice experiment in the context of general practice was conducted. This study showed that most people thought their GP demonstrated behaviour likely to result in the production of non-health outcomes. The results showed that although all the non-health outcomes were, to some extent, preferred by respondents, trust was most important, followed by legitimation and recognition of and support for emotional distress. Once again, these results point to the importance of context in the evaluation of health care from the patient's perspective. While still being perceived as positive aspects of health care, the provision of information and acting autonomously or participating in decisions about their health care were the non-health outcomes considered least important by patients

In Chapters 1 and 2, we examined two key components of heathy dietary patterns, specific types of dietary fat and consumption of fruit and vegetables, in relation to total and cause-specific mortality in two prospective cohort studies, the Nurses’ Health Study and the Health Professionals Follow-up Study. Dietary intake was assessed using semi-quantitative food frequency questionnaires at baseline and updated every 2 to 4 years. In Chapter 1, we found that higher saturated and trans fat intakes were associated with higher mortality, whereas polyunsaturated and monounsaturated fat intakes were inversely associated with mortality. Replacing 5% of energy from saturated fats with equivalent energy from polyunsaturated fats and monounsaturated fats was associated with 27% and 13% estimated reductions in total mortality, respectively. Intake of n-6 polyunsaturated fat, especially linoleic acid, was inversely associated with mortality, while marine n-3 polyunsaturated fat intake was associated with a modestly lower total mortality. In Chapter 2, we observed an inverse and nonlinear association between fruit and vegetable consumption and mortality. Consumption of five servings of fruit and vegetables daily, two servings for total fruit and three servings for total vegetables, were associated with the lowest total mortality, but above that level, higher consumptions were not associated with additional risk reductions. Higher consumptions of most fruit and vegetable subgroups were associated with lower risks of total mortality, whereas higher intakes of starchy vegetables such as peas and corn were associated with slightly higher risk of total mortality. In Chapter 3, we investigated the interrelationships between plasma ceramide concentrations, Mediterranean dietary pattern and cardiovascular disease (CVD) in the PREDIMED trial, a randomized controlled trial on the Mediterranean diet for primary prevention of CVD, using a case-cohort design. We observed strong positive associations between plasma ceramide concentrations and CVD risk. The association between ceramide concentration and incident CVD significantly varied by intervention groups. A Mediterranean diet may mitigate the deleterious effects of elevated plasma ceramide concentration. In summary, our findings from the three studies support current dietary recommendations to replace saturated and trans fat with unsaturated fats, increase fruit and vegetable consumption and adopt healthy Mediterranean-style dietary patterns.

Thesis (Ph. D.)--University of Sydney, 2002.
Includes tables and questionnaires. Title from title screen (viewed Apr. 28, 2008). Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Dept. of Public Health and Community Medicine, Faculty of Medicine. Includes bibliography. Also available in print form.

The perfectionism and health literature suggests that maladaptive perfectionism is associated with a plethora of negative health outcomes and adaptive perfectionism with both favourable and unfavourable health outcomes. Additionally, a small amount of research has proposed maladaptive perfectionists may refrain from engaging in preventive health behaviours whilst adaptive perfectionists may engage more readily. This thesis explored the differences between adaptive and maladaptive perfectionism in relation to engagement in preventive health behaviours as well as addressing possible intervening variables in the perfectionism, engagement relationship (e.g. self-presentation, perceived stress, self-efficacy and affect). Four studies were carried out. In study 1, (N=370), using a sample of university students, results identified maladaptive perfectionism to be associated with decreased engagement in preventive health behaviours and adaptive perfectionism with increased engagement. Self-concealment (a self-presentational strategy) was found to partially mediate the perfectionism, engagement relationship for maladaptive perfectionists. In study 2, (N= 875), again with university students, (using a different conceptualisation of perfectionism), results showed that although ‘type’ of perfectionism did not interact with perceived stress to influence engagement, significant differences were identified between type of perfectionism and a number of health related variables. In study 3, results from a qualitative study involving university students showed that factors inherent in the university environment as well as factors characteristic of perfectionism prohibited engagement in preventive health behaviours. In study 4, using a general population sample, adaptive perfectionism was associated with greater engagement but no relationship was found for maladaptive perfectionism. Various factors were found to moderate and mediate the perfectionism, engagement relationship for adaptive perfectionism and adaptive perfectionism was associated with more benefits to engagement and maladaptive perfectionism with more barriers to engagement in preventive health behaviours. In summary, the results from this thesis suggest there are differences between the two perfectionism dimensions in relation to engagement and other health variables, although this may be dependent on the population/context being studied. More research is warranted to explore the perfectionism, engagement relationship specifically looking at different populations to establish whether maladaptive perfectionists in a university environment represent a particularly vulnerable group.

Landscape development[1] can provide many benefits, including the reduction of stormwater runoff and the creation of habitats for wildlife. It can also provide health benefits. Researchers, such as Roger Ulrich and Rita Berto have demonstrated that views of trees and other vegetation are associated with lower blood pressure and reduced recovery times in hospitals and that environments with more natural elements may lessen mental fatigue (R. Ulrich 1984) and (Berto 2005). As rebuilding in New Orleans continues 11 years after Hurricane Katrina, landscape development has been limited or lacking, especially in the redevelopment of commercial properties. Two prominent reasons for this deficiency are a lack of funding and, until August of 2015, the absence of a comprehensive landscape ordinance. The purpose of the research presented here is to determine the degree to which community residents express a preference for healthier commercial environments. As part of my research, I measured community perceptions of four potential redevelopment concepts for a blighted strip shopping center utilizing attention restoration theory (ART), which postulates that certain environmental qualities contribute to reductions in mental fatigue. I found that commercial environments with the most quality landscaping[2] are those that neighborhood residents most prefer and are most conducive to better health. Keywords: mental fatigue, attention restoration theory, perceived restoration scale, commercial landscape quantity, public health, healthy urban environment [1] Refer to operational definitions (pages 4-6). [2] Refer to operational definitions (pages 4-6).

La percentuale della popolazione anziana tenderà ad aumentare nei prossimi anni, implicando la necessità di porre maggiore attenzione allo stato di salute di questa categoria di popolazione, per promuovere un sano invecchiamento. La salute orale è parte integrante della salute generale di un individuo, condizionandone la qualità della vita. Le patologie orali, associate a una riduzione della funzione masticatoria, possono influenzare negativamente lo stato nutrizionale di un individuo, esponendolo a un aumentato rischio di outcomes di salute avversi. Durante la pratica clinica quotidiana, i clinici potrebbero avere la necessità di misurare oggettivamente la performance masticatoria del proprio assistito, con lo scopo di valutarne la funzione orale e il grado di disabilità orale. Lo scopo dello studio è di proporre un metodo oggettivo in grado di misurare la performance masticatoria umana e di verificarne l’impatto sullo stato di salute generale di soggetti anziani auto-sufficienti e di soggetti istituzionalizzati. In generale, sebbene la salute orale sia ritenuta un fattore determinante per la salute sistemica e per il benessere di un individuo, questa è spesso trascurata, specialmente nei soggetti fragili che hanno bisogno di assistenza quotidiana, a causa delle difficoltà ad accedere alle cure odontoiatriche. Lo sviluppo di nuove strategie (Teledentistry) potrebbe essere utile per promuovere un sano invecchiamento. In una società che sta invecchiando, programmi di educazione alla salute orale, adeguate politiche sanitarie e un aumento della consapevolezza tra la cittadinanza, possono contribuire al raggiungimento di un sano invecchiamento orale. In generale, il team sanitario geriatrico dovrebbe ricoprire un ruolo di primaria importanza nell’iniziale bilancio di salute orale del proprio assistito, co-operando in un ambiente volto a promuovere la salute orale, prendendosi quindi cura della salute generale e del benessere della popolazione anziana.
According to recent studies, the percentage of elderly population will significantly increase over the next few decades, implying the need to pay more attention to the health of elderly to promote healthy ageing. Oral health is an important part of general health, affecting the quality of life of an individual. Oral disorders, associated with a reduced masticatory function, negatively affect the nutritional status of older adults, exposing them to several acute and chronic diseases. The subjects with oral impairment may not have an adequate nutritional status, increasing the risk of general health related adverse effects. During their daily office practice, clinicians should be required to objectively evaluate human mastication, aiming not only at evaluating oral function, but also at providing information about patient impairment. The Research Project aims at proposing an objective method able to assess human masticatory performance and investigating the impact of masticatory performance on general health status of self-dependent and institutionalized elderly. Overall, even if oral health is deemed to be a crucial factor for general health and well-being, it is often neglected, especially in older adults and in those who are frail and care dependent. Several older adults face difficulties in accessing dental care, so that the development of new strategies aimed at enhancing general and oral health status, such as Teledentistry, should be pursued. In an ageing society, educational interventions about oral health addressed to patients themselves and caregivers, appropriate oral health policies, and citizens empowerment and involvement can contribute to the promotion of oral health in elderly. Geriatric healthcare team members should play an important role in the initial oral health assessment, achieving an interprofessional collaborative environment aimed at promoting oral health and, thus, taking care of the overall health and well-being of older adults. 

In common with other areas of public services, recent years have seen a shift in the National Health Service (NHS), with increased power and authority transferring from professionals towards the users of services. As a result, user involvement has come to form a central element of government policy on public services, and health in particular, with a series of specific policy commitments to give users a stronger voice and to involve them in the health service having been published by both the Westminster and Scottish parliaments. These seek to increase users’ involvement in making decisions about their own care and treatment, in examining and improving the quality of services and in policy and planning activity. In doing so, this policy aspires to respond to the changing culture of personal and societal expectations of health and the health service; to build democratic participation in the difficult targeting and rationing decisions faced by health agencies and, thus, to help renew public trust and strengthen confidence in the NHS. These are ambitious aims with far-reaching implications as they represent a transformation in the interaction between users, health professionals and health policy makers. This thesis examined how this policy has been understood and implemented in the NHS by exploring the scope, relevance and quality of the user involvement processes available in three health service settings. In order to develop a better understanding of the issues in user involvement it explored the nature of user participation; the character of user representation and the barriers and facilitators to user involvement in maternity, gynaecological oncology and mental health services. The study examined the response to this policy within these three settings; the functioning of existing user involvement mechanisms and their capacity to involve users in determining their individual health care and in shaping health services and policy to their definition of need. From this examination it defined the key features of a model process for user involvement within the professional service culture and organisational ethos of the NHS. The study then drew conclusions on the capacity of these current user involvement processes to deliver on the policy directive to develop both individual treatment and health services in ways that are responsive and accountable to users. Finally, the thesis identified those areas that require further research before proposing the lessons for the further development of this significant and potentially influential policy directive.

It is well documented that British South Asians (BSAs; people of South Asian origin residing in the UK) experience an elevated risk of developing coronary heart disease. The disease rate is approximately 50% higher than the national average. Many causal factors for this unfavourable risk profile have been put forward indicating that it is likely to be explained by a complex interplay of both genetic and lifestyle factors. Components of the BSA diet coupled with an inactive lifestyle have been identified as modifiable risk factors which could play a significant role in the prevention of this disease. Despite the identification of modifiable risk factors, health promotion interventions with measurable behavioural outcomes designed for this population are sparse. The testing of prevention strategies amongst this population is of vital importance. This thesis aimed to address the current gap in the literature by designing and testing a novel health promotion intervention specifically for the younger BSA population by means of a randomised controlled trial. The intervention was informed and underpinned by two prominent theories in the field of health research - prospect theory and the theory of planned behaviour. A novel variable, cultural sensitivity, was also manipulated. The intervention aimed to target change in two behaviours - the reduction of overall fat and an increase in physical activity. The intervention was informed and designed using the findings of a .systernatic review of the message framing literature (Chapter 2), a qualitative study which aimed to identify the barriers and facilitators to healthy living for BSAs (Chapter 3) and by the design and piloting of theory-driven behaviour change DVDs (Chapter 4). The findings of the research showed that the effects of message framing and cultural sensitivity are different for a) the type of behaviour being promoted (dietary vs. physical activity) and b) BSA males and females. It appears that BSA males and females respond differently to health promotion information relating to physical activity, yet no gender differences were apparent for dietary behaviours. These findings suggest that BSA males and females may require tailored approaches for health behaviour change interventions and there was evidence to suggest that there may be some utility in manipulating health information, both in terms of framing and cultural sensitivity, for the BSA audience. The findings did not provide any support for the mediating role of social cognitive variables on health behaviour change.

The concept of health promotion is an alternative and emerging orientation. Here the belief is that all people have strengths and are capable of determining their own needs, finding their own answers, and solving their own problems. Most health care professional have been educated in the medical model of health. In this model, the health care professional, especially the physician, plays an active part as an expert on disease; the patient or client has essentially a passive role, and the disease rather than the person is the focus. The role of health care professionals in health promotion is an important one and will continue to expand with the new focus of the province of Alberta's health system. The focus of that system, and other health systems in Canada and abroad, is increasingly upon health promotion rather than disease treatment. The purpose of this study was to determine the perceptions of a variety of health care professionals working in the community and in the hospital setting relating to health promotion. The study takes a non-experimental approach utilizing a descriptive design. All professional staff including registered nurses, occupational therapists, recreational therapists, physiotherapists, respiratory therapists, social workers, dental workers, nutritionists, speech-language pathologists, and physicians working in Palliser Health Authority were asked to participate in the survey. Two hundred and thirteen staff responded to a questionnaire desgined to reflect their perceptions on the importance of health promotion, determinants of health, principles of health promotion, and skills and knowledge of health promotion. Staff were also asked to identify health promotion activities occuring at their work site, possible barriers to health promotion, and what was needed regarding training and support. Some of the major findings include: 1) Staff perceive health promotion to be an important part of their job. However staff working in the community perceive health promotion to be more important than those working in the hospital. Physicians were the least positive about questions pertaining to the importance of health promotion. 2) Staff perceive that the purpose of health promotion is to strengthen peoples' control over their health, but responses also indicate uncertainty concerning how control is to be defined and effected. 3) When asked to identify health promotion activities at their work site, the majority of staff pointed to the provision of information to individuals and groups. Community development was listed by very few staff. 4) When staff were asked to identify barriers to health promotion they identified the following in the order: lack of resources, old attitudes about health and health promotion, lack of support from the organization and doctors, lack of knowledge/education, and lack of communication between health care workers.
v, 101 leaves : ill. ; 28 cm.

Background: Oral and dental diseases is a major part of the global disease burden. Poor oral health has a significant impact on the general well-being of people. In contrast with prior decades high rates of oral diseases may be found in low- and middle income countries. Populations that are particularly vulnerable are more likely to develop poor oral health. As a consequence of human distress related to war, poverty and natural disasters the accomplishments of humanitarian aid organizations has a direct impact on people´s health and well-being. Purpose: The aim of the present study is to examine the International Red Cross and Red Crescent Movement as well as Doctors without borders concerning documents and guidelines on oral health. A further aim is to explore the knowledge of oral health related topics of delegates from the International Federation of the Red Cross and Red Crescent Societies (IFRC). Method: The study is designed as a literature review and a questionnaire survey. Results: Within the International Red Cross and Red Crescent Movement and Doctors Without Borders there are a limited number of guidelines on oral health and they are rarely mentioned in the same documents as non-communicable diseases (NCDs). The responses of the study revealed that the participants generally have a limited knowledge about measures on oral health in the IFRC. Conclusion: Both the literature review and the questionnaire survey study confirms that there is an absence of clear and specific guidelines on oral health care related activities within IFRC.
Bakgrund: Mun- och tandsjukdomar utgör en stor del av den globala sjukdomsbördan. Dålig mun- och tandhälsa har en stark påverkan på det allmänna välbefinnandet. I motsats till tidigare, ses idag höga frekvenser av karies även i låg- och medelinkomstländer. Populationer vilka befinner sig i extra utsatta kontexter löper större risk att utveckla dålig munhälsa. Som en följd av mänskligt lidande i form av händelser relaterade till krig, fattigdom och naturkatastrofer har aktiviteter utförda av humanitära hjälporganisationer en direkt inverkan på hälsa och välbefinnande. Syfte: Syftet med föreliggande studie är att studera dokument och riktlinjer rörande munhälsa inom Internationella Röda korset och Röda halvmånen och Läkare utan gränser. Ett ytterligare syfte är att undersöka kunskapen om hälsorelaterade frågor kring munhälsa hos delegater från Internationella federationen för Röda Korset och Röda Halvmånen (IFRC). Metod: Studien är utförd som en litteratur-sammanställning och som en enkätundersökning. Resultat: Inom Internationella Röda korset och Röda halvmånen samt Läkare utan gränser återfinns begränsat antal riktlinjer rörande oral hälsa vilka dock sällan nämns i samma dokument som icke-smittsamma sjukdomar (NCDs). Av enkätsvaren i studien framgår det att de medverkande generellt har en begränsad kunskap kring åtgärder rörande munhälsa inom IFRC. Konklusion: Deltagarna i denna studie bekräftar resultaten i litteraturstudien om en avsaknad av tydliga och konkreta riktlinjer för munhygienrelaterade aktiviteter inom IFRC.

This thesis address one of the most important topics for the human being; health. Specifically, the research is about the deficiencies of the health system in Mexico. This paper shows the importance, how the system works and its current situation in the country. The purpose of this research is, based on the Pareto principle (20% vs 80%), to find how to solve most problems with the least possible investment.   It was found that the common denominator in the problems was the process and flow of information of the patients; specifically, the health records. The researchers address the issue at first explaining in a deep way the health records to highlight their importance in the health care system. In order to corroborate this finding in the literature; The researchers designed an interview, which was applied to physicians from the two main health institutions in Mexico in order to collect the necessary information to develop the thesis.   Since the design of the research is qualitative; the necessary social context is given to be able to understand the analysis and the results; likewise, the authors explain in detail the methodology used.   In spite of other important factors that were found such as the lack of results despite the investment and deficiencies in the infrastructure; It was concluded that, in fact, most of the problems were derived from the problems of health records. These results are important because it gives a parameter of what must be corrected first in order to have the expected results and a better health system.